Safety SAM

• Prepared by

• Location
  Address

• Pronto Call

• Date & Time

  Date

• Is there a Sub Permit Required for this Task?

  Select Hot Works Confined Space Ceiling and Underfloor Access Critical Services Isolation Excavation Fire Service Isolation Proximity to LV/HV ACM Disturbance Blind Penetration Working at Heights No Sub permits Required

  • Hot Works
  • Confined Space
  • Ceiling and Underfloor Access
  • Critical Services Isolation
  • Excavation
  • Fire Service Isolation
  • Proximity to LV/HV
  • ACM Disturbance
  • Blind Penetration
  • Working at Heights
  • No Sub permits Required

Stop and Think About the Task

• IS THE TASK A HIGH RISK OR NON-ROUTINE TASK?

  Safe

  At Risk

  N/A

• HAVE I PARTICIPATED IN THE DEVELOPMENT OF A JSEA. If No DO NOT COMMENCE TASK

  Safe

  At Risk

  N/A

• HAVE I SIGNED A SITE SPECIFIC SWSP FOR THIS TASK?

  Safe

  At Risk

  N/A

• HAVE I BEEN DEEMED COMPETENT FOR THE TASK I AM ABOUT TO COMPLETE.

  Safe

  At Risk

  N/A

• Am I completing this Risk Assessment whilst Inspecting the specific job site?

  Safe

  At Risk

  N/A

• Will I be performing this task continuously for two hours or more?

  Safe

  At Risk

  N/A

• Will I be Exposed to any rotating parts, sharp edges or pinch points?

  Safe

  At Risk

  N/A

• Is the equipment fit for purpose and in good order?

  Safe

  At Risk

  N/A

• Are there any hazards that could cause me, or anyone else, to Slip, Trip or Fall? If yes please list them:

  Safe

  At Risk

  N/A

What Else Could Go Wrong

Take Action To Control the Hazard